All reproductive health facilities should have up-to-date policies
and procedures for managing persons who have survived or experienced
sexual violence that are in line with local law. Whether comprehensive
services are provided on-site or through referral, providers need to be
clear about the protocol to be followed and how to manage crisis
situations. They should have the necessary supplies, materials and
referral contact information in order to deal confidentially,
sensitively and effectively with people who have experienced sexual
violence.

Step 1: Be prepared

The following services should be available, on-site or through
referral, for patients who have experienced sexual violence:

essential medical care for any injuries and health problems;

collection of forensic evidence;

evaluation for STI and preventive care;

evaluation of pregnancy risk and prevention, if necessary;

psychosocial support (both at time of crisis and long-term);

follow-up services for all of the above.

Step 2: Initial evaluation and consent

Survivors of sexual assault have experienced a traumatic
event and should be rapidly evaluated to determine whether they need
emergency medical, psychological or social intervention. It is important
to remember that the trauma of the event may make parts of the
examination difficult. Explain carefully the steps that will be taken
and obtain written informed consent from the patient before proceeding
with examination, treatment, notification or referral.

Step 3: Documentation and evidence

A qualified provider who has been trained in the required
procedures should perform the examination and documentation of evidence.
The examination should be deferred until a qualified professional is
available, but not for longer than 72 hours after the incident. It is
the patientís right to decide whether to be examined. Treatment can be
started without examination if that is the patientís choice. For minors
under the age of consent, local guidelines may dictate how to manage the
personóusually parental consent is required. If at all possible, do
not deny adolescents immediate access to medical services.

Where facilities or referral for a more complete examination are not
available, the following minimal information should be collected:
date and time of assault; date and time of examination; patientís
statement; and results of clinical observations and any examinations
conducted. Such information should be collected or released to the
authorities only with the survivorís consent. Be aware of legal
obligations that will follow if the assault is reported and goes to
legal proceedings. Ideally, a trained health care provider of the same
sex should accompany the survivor during the history-taking and
examination.

A careful written record should be made of all findings during the
medical examination. Pictures to illustrate findings may help later in
recalling details of the examination.

Step 4: Medical management

The medical management of the survivor includes treatment of any
injuries sustained in the assault, and initial counselling. Emergency
contraception and STI prophylaxis should be offered early to survivors of
sexual violence. For many women, the trauma of the event may be
aggravated and prolonged by fear of pregnancy or infection, and knowing
that the risks can be reduced may give immense relief.

Emergency contraception

Emergency contraceptive pills can be used up to 5 days after
unprotected intercourse. However, the sooner they are taken, the more
effective they are. Several regimens existóusing levonorgestrel or
combined oral contraceptive pills (see Box 6.2).

A second option for emergency contraception is insertion of a
copper-bearing IUD within 5 days of the rape. This will prevent more
than 99% of pregnancies. The IUD may be removed during the womanís next
menstrual period or left in place for continued contraception. If an IUD
is inserted, make sure to give full STI treatment as recommended
in Treatment table 13.

If more than 5 days have passed, counsel the woman on availability of
abortion services (in most countries, post-rape abortion is legal). A
woman who has been raped should first be offered a pregnancy test to
rule out the possibility of pre-existing pregnancy.

Postexposure prophylaxis of STI

Another concrete benefit of early medical intervention following rape
is the possibility of treating the person for a number of STIs. STI
prophylaxis can be started on the same day as emergency contraception,
although the doses should be spread out (and taken with food) to reduce
side-effects such as nausea.

The incubation periods of different STIs vary from a few days for
gonorrhoea and chancroid to weeks or months for syphilis and HIV.
Treatment may thus relieve a source of stress, but the decision about
whether to provide prophylactic treatment or wait for results of STI
tests should be made by the woman.

Treatment table 13 lists options that are effective whether taken
soon after exposure or after the appearance of symptoms.

Treatment table 13. STI presumptive treatment options for adults

Coverage

Option 1

All single dose, highly effective. Choose one from
each box
(= 3 or 4 drugs)a

erythromycin
12.5 mg/kg of body weight orally 4 times a day for 7 days

12 years or older,

use adult protocol

Trichomoniasis

metronidazolec 5 mg/kg of body weight
orally 3 times a day for 7 days

12 years or older,

use adult protocol

a. Additional antibiotic treatments for gonorrhoea are
given in Annex 4.

b. If erythromycin is chosen for syphilis, then only 3
drugs should be used for children.

c. Patients taking metronidazole should be cautioned to
avoid alcohol.

Postexposure prophylaxis of HIV

The possibility of HIV infection should be thoroughly discussed as it
is one of the most feared consequences of rape. At present, there is no
conclusive evidence on the effectiveness of postexposure prophylaxis
(PEP) in preventing infection following sexual exposure to HIV, and PEP
is not widely available. If PEP services are available, rape survivors
who wish to be counselled on the risks and benefits should be referred
within 72 hours. The provider should assess the personís knowledge and
understanding of HIV transmission and adapt the counselling
appropriately. Counselling should take into account the local prevalence
of HIV and other factors (trauma, other STI exposure) that could
influence transmission. If the person decides to take PEP, two or three
antiretroviral drugs are usually given for 28 days.

Prophylactic immunization against hepatitis B

Hepatitis B virus (HBV) is easily transmitted through both sexual and
blood contact. Several effective vaccines exist although they are
expensive and require refrigeration. If HBV vaccine is available, it
should be offered to survivors of rape within 14 days if possible. Three
intramuscular injections are usually given, at 0, 1 and 6 months (see
instructions on vaccine package as schedules vary by vaccine type). HBV
vaccine can be given to pregnant women and to people with chronic or
previous HBV infection. Where infant immunization programmes exist, it
is not necessary to give additional doses of HBV vaccine to children who
have records of previousvaccination. Hepatitis immune globulin is not
needed if vaccine is given.

Tetanus toxoid

Prevention of tetanus includes careful cleaning of all wounds.
Survivors should be vaccinated against tetanus if they have any tears,
cuts or abrasions. If previously vaccinated, only a booster is needed.
If the person has never been vaccinated, arrangements should be made for
a second vaccination one month later and a third 6 months to one year
later. If wounds are dirty or over 6 hours old, and the survivor has
never been vaccinated, tetanus immune globulin should also be given.

Step 5: Referral to special services

Following the initial provision of care, referrals may be needed for
additional services such as psychosocial support. An evaluation of the
personís personal safety should be made by a protective services agency
or shelter, if available, and arrangements made for protection if
needed. Referral for forensic examination should be made if this is
desired but could not be adequately performed at the clinic visit.

It is essential to arrange follow-up appointments and services during
the first visit. The woman should be clearly told whom to contact if she
has other questions or subsequent physical or emotional problems related
to the incident. Adolescents in particular may need crisis support as
they may not be able or willing to disclose the assault to parents or
carers.

Contents
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Infections of the male and female reproductive
tract and their consequences: